“A pox of this gout! or a gout of this pox! for the one or the other plays the rogue with my great toe.”
— William Shakespeare (1564–1616), English poet and playwright
Falstaff, in Henry IV, Part 2, act 1, sc. 2, l. 243-5.

Uncanny  that Shakespeare diagnosed gout and even immortalized it in a play!

For indeed, gout usually presents as redness, swelling, pain, and tenderness of the big toe, specifically the 1st MTP (metatarsophalangeal joint) or joint of the great toe. This is a condition called podagra. He was also right in his observation that gout is a “lifestyle disease” as these are maladies brought on by lechery (pox = syphilis) and drinking (gout).

What causes gout. Gout occurs when uric acid, a natural by-product of the breakdown of purines, accumulates. Purines are natural substances found in our body’s cells that are essential building blocks. They can also be found in plants and animals. Now normally, ingested food and drink with purines are broken down into uric acid. Uric acid in turn is converted to allantoin with the help of the enzyme uricase. The problem is that some people do not have uricase or at least it isn’t working right. So what happens is that there’s an overload of uric acid (hyperuricemia) in the blood and with a combination of a high purine diet (foods loaded with purine), alcohol, or the use of diuretics, the excess uric acid turns into crystals.

These crystals deposit (painfully) in the joints, kidneys, and soft tissues. For some reason, some people with high uric acid still don’t get gout. These are the lucky ones.

Risk factors. Textbooks report that gout is most common in men between 30 and 45 and in women between 55 and 70. To develop gout, these risk factors are contributory: Overeating (especially meat and seafoods), fasting, excessive alcohol intake (beer, vodka, rum, gin, and whiskey), injury or undergoing surgery, obesity, medication, such as diuretics that alter urate concentrations.

Signs and symptoms. Gout is most often a clinical diagnosis – that is, a good doctor knows what it is when he sees it. So as mentioned, an acute gout attack presents with: Severe joint pain, redness, swelling, tenderness, skin desquamation (skin sloughing off over inflamed area), swearing never to take alcohol (for the time being).

Diagnosis. Visit your family physician, endocrinologist, rheumatologist, rehabilitation medicine specialist, or lest I forget, your orthopedic surgeon. The most important laboratory test is an analysis of the [involved] joint fluid.

Under the microscope, monosodium urate crystals will be seen and this Adsclinches the diagnosis. However, the American College of Rheumatology (ACR) has a “Preliminary Criteria for Gout” and your good doctor refers to this for guidance.

Treatment. The doctor’s goal is simple: Get rid of the pain – fast. To do this, there are first-line therapies and these include: NSAIDs or non-steroidal anti-inflammatory drugs (examples: indomethacin, naproxen) or COX-2 inhibitors (celecoxib, etoricoxib) and corticosteroids (prednisone, methylprednisolone). A second-line drug is colchicine but it is usually given to patients who cannot tolerate NSAIDs or COX-2 inhibitors because side effects are bothersome. Colchicine causes diarrhea, abdominal cramps, nausea, and vomiting. After an acute gout attack, the doctor will work on lowering the overproduction of uric acid. Some of the drugs used are allopurinol and probenecid. In the US, a drug comparable to allopurinol is being studied. It is called febuxostat.

Prevention. According to HealthCastle.com, a reliable dietary advice website, the foods to avoid (high-purine) that may trigger gout are the following: Anchovies (dilis), mackerel, sardines, sweetbreads, organ meats (brain, kidney, pancreas, liver, etc.), and gravy. To take in moderation: Beef, pork, fish, and other seafoods, asparagus, cauliflower, mushrooms, beans (including mung beans or munggo), dried peas, and spinach. Urinary uric acid can be diluted by drinking more water (about 2-3L) a day and of course, hold the beer!

It’s time we leave gout in literature and out of our lives.

Dr. Pujalte is an orthopedic surgeon. E-mail jspujalte@yahoo.comfrom